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0 ! <br /> -The free Adobe Reader may be used to dew and complete this form. However,software must be purchased to complete,save,and reuse a saved farm. <br /> File Original with DWR State of Califomia DWR Use Only-Do Not Fill In <br /> Well Completion Report <br /> Page of I / Rekrfa lnafnx9on Pamphlet �StalTe Wdl Numbed.ile Number <br /> Owners Well Number t./— 6 No. e0P95025 J W Latitude Long'.. <br /> Date Work Began ��O� Date Work Ended -t(s.3 <br /> Local Permit Agenq ., <br /> Permd Number O '7 Permit Dale L jec APN I KSIOther <br /> Geologic Log fil Well Owner <br /> Orientation Vertical 0 Horizontal OAngle Specify Name 0i <br /> Miling_Method I'C r.,r . Drilling Fluid Mailing Address ZO �� /- <br /> Depth from Surface Description li iCo State 6- 7 -Ea—k&- <br /> Fee w Feel Describe matedal.orain size,color,etc C' <br /> 11 ly rJ WeGation <br /> l✓a Address 01 1GLOa <br /> City ~County Ir , <br /> Latitude N Longftude <br /> C". Min. sac Dap. Mn. Sec <br /> Datum Decimal Lat. - Decimal Long. <br /> APN Book Page - Parcel <br /> �• - Townshi Ra jnl Section <br /> - LOCa11j011Activl <br /> L aketUi nhustbe dme,. h.eaanrr'aim N' ted.) O New Well. <br /> O Modification/Repair <br /> ... '.\ O Deepen <br /> O Other <br /> Destroy <br /> _ _. wem•csaoac coo• <br /> Planned Uses:- <br /> h O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Imgatlon []industrial <br /> S O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> -- O Injection <br /> 40 Monitoring <br /> % O Remediation <br /> A.. O Sparging <br /> O Test Well <br /> �. <br /> ,: euma«eewmse.Mrc.awlamreea.aawo,sa.».._ OVapor Exlrsdion <br /> O Other <br /> - PIrM Ncc«.h.>Ip <br /> -:. ater Level a'De eld-d Corn feted:Well <br /> Depth to first water (Fee surface) <br /> Depth to Static <br /> Water Level F ate Measured <br /> Total Depth of Sodng Estimated Yaald - _(GPM) Test Type <br /> Total Depth ofComple Feet Test Le (Hours)Total Drawdown_(Feet) <br /> -. :'M be representative.of a wens Ion term..yield. <br /> Casih s ` `nular Material <br /> Depth frau Boreholedy Wall oubido Screen Slot Spee Depth from <br /> Surface Diem/lW Type Thickness Diameter Type if Any Surface Fill Description <br /> Fee a Feet Inches - Indies Inches Inches feet.:.m Feet <br /> Atfa¢hments Celtlfication.5iateinent <br /> ❑Geologic fag 1.the undersigned,oerti fy the 's pert is te` ( ' rale�td s f my knowledge and belief <br /> ❑Well Construction Diagram Nan a L� <br /> ❑Geophysical Log(s) CA <br /> ❑Sola Water Chemical Analyses s°m <br /> ❑Dow Signed <br /> A..eh.dsmiw leforrnetion vn.em. car. wmarwda Conlreapr G57 License Number <br /> DAR 108 REV.14N0e IF ADDITIONAL SPACE 19 NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />